1. Recent Advances in Surgical Management of Complex Cryptoglandular Anal Fistula
YK Fong, Queen Mary Hospital

2. Agenda Introduction Management approach of anal fistula
Etiology and pathogenesis
Classification
Management approach of anal fistula
Assessment
Surgical options
Recent advances in surgical treatment

3. Etiology and Pathogenesis
Cryptoglandular (90%)
Extension of sepsis from infected anal glands in the intersphincter space
Non-cryptoglandular
Crohn’s disease
Tuberculosis, actinomycosis
Malignancy
Hidradenitis suppurativa
Radiation
HIV infection
Immunocompromised (chemotherapy/ diabetes)

4. Classification 1) Intersphincteric 2) Transphincteric
3) Suprasphincteric
4) Extrasphincteric

5. Anal Fistula Classification
Complex: Treatment poses a high risk of incontinence
Postoperative recurrence
Multiple tracts
Tract crosses >30-50% of
external sphincter muscle
Anterior in females
Pre-existing incontinence
American Gastroenterological Association
American Gastroenterological Association

6. Complex Anal Fistula -Management Approach
Assessment
To rule out ongoing anorectal sepsis
To delineate the anatomy of fistula tracts
To look for non-cryptoglandular causes
To look for any causes of poor wound healing
Immunocompromised
steroid application 
Definitive treatment
Two syringes
fibrinogen, factor XIII,
aprotinin, fibronectin
thrombin and calcium solution
A simple and repeatable technique
Success rate improved by repeated injections
Not interfere or compromise subsequent surgical
options
Avoid prolonged discomfort from wound dressing
Better in more complex and longer fistula tracts
Success rate: 14 to 85%

7. Principles of Treatment
Control of sepsis
Initial seton placement
6-12 weeks
Allow adequate time for assessment
Definite individualized surgery
Closure of fistula
Maintenance of continence

8. Surgical Treatment Options
Conventional approaches
Cutting Seton placement
Staged fistulotomy
Anorectal advancement flap
Continence preserving approaches
Fibrin glue
Anal fistula plug
Ligation of Intersphincteric Fistula Tract (LIFT)
Video-Assisted Anal Fistula Treatment (VAAFT)
Although complex fistulas are rare, various treatmentoptions are available, such as debridement and fibringlue injection, endorectal advancement flap closure, andthe use of seton and/or staged fistulotomy.1,4–8 Thesemethods have some elements of morbidity, particularly regardingrecurrence rates and incidence of fecal incontinence.

9. LIFT Procedure (Ligation of Intersphincteric Fistula Tract )
Rojanasakul et al. from Bangkok in 2007
Success rate: 17/18 (94.4%)
Rojanasakul, Tech Coloproctol 2009

10. LIFT Procedure: A Simplified Technique for Anal Fistula
Incision at the intersphincteric groove Identification of the intersphincteric tract Ligation of intersphincteric tract close to the internal opening Removal of intersphincteric tract Scraping out all granulation tissue Suturing the defect at external sphincter complex

11. Rationale of LIFT Procedure
Prevention of recurrent sepsis
Avoid entrance of fecal particles via internal opening
Remove intersphincteric fistula tract
Intermittent closed septic foci and persistent sepsis due to compression between sphincter muscles

12. LIFT Procedure Less injury to anal sphincter Short hospital stay
Short healing time
Primary healing rate 82.2% (37/45)
Shanwani et al DCR 2010

13. BioLIFT Procedure A modification of LIFT Procedure
Placement of biologic mesh in the intersphincteric space
Barrier to re-fistulization
BioLIFT
Recently, a modification of the LIFT procedure has been described. After the fistula tract is identified and divided, a biologic mesh is placed in the intersphincteric space to act as a barrier to re-fistulization. A video presented at the 2010 American Society of Colon and Rectal Surgeons meeting demonstrated this technique with promising results in a single surgeon series. This procedure entails
It is postulated that the benefit seen in this series derives
from the bioprosthetic graft acting as a physical barrier
to separate the transected ends of the fistula tract. The
ability of the bioprosthetic grafts to tolerate contamination
and be remodeled without a foreign body reaction makes
them the most appropriate material to us in this application.
Given our experience with the use of the small intestinal
submucosal graft (Biodesign, Cook Surgical, Bloomington,
IN) for rectovaginal fistulas, it was the only
bioprosthetic used in this series.
There are 2 potential drawbacks of the BioLIFT technique
when compared with the LIFT procedure. To obtain
the desired barrier effect, the bioprosthetic must overlap
the closure of the fistula tract by at least 1 to 2 cm in all
directions. This requires amore extensive dissection in the
intersphincteric space than is usual for the LIFT procedure.
The physiologic consequences of this dissection have not
been studied. The other issue is the relatively high cost of
the bioprosthetic materials. This series does not conclusively
demonstrate a benefit that would justify the increased
cost of the use of a bioprosthetic.
C. Neal Ellis et al. Meeting of The American Society of Colon and Rectal Surgeons 2012

14. BioLIFT Procedure Bioprosthetic grafts Healing rate: 94% (29/31)
Tolerate contamination
Remodeling without a foreign body reaction
Healing rate: 94% (29/31)
BioLIFT
Recently, a modification of the LIFT procedure has been described. After the fistula tract is identified and divided, a biologic mesh is placed in the intersphincteric space to act as a barrier to re-fistulization. A video presented at the 2010 American Society of Colon and Rectal Surgeons meeting demonstrated this technique with promising results in a single surgeon series. This procedure entails
It is postulated that the benefit seen in this series derives
from the bioprosthetic graft acting as a physical barrier
to separate the transected ends of the fistula tract. The
ability of the bioprosthetic grafts to tolerate contamination
and be remodeled without a foreign body reaction makes
them the most appropriate material to us in this application.
Given our experience with the use of the small intestinal
submucosal graft (Biodesign, Cook Surgical, Bloomington,
IN) for rectovaginal fistulas, it was the only
bioprosthetic used in this series.
There are 2 potential drawbacks of the BioLIFT technique
when compared with the LIFT procedure. To obtain
the desired barrier effect, the bioprosthetic must overlap
the closure of the fistula tract by at least 1 to 2 cm in all
directions. This requires amore extensive dissection in the
intersphincteric space than is usual for the LIFT procedure.
The physiologic consequences of this dissection have not
been studied. The other issue is the relatively high cost of
the bioprosthetic materials. This series does not conclusively
demonstrate a benefit that would justify the increased
cost of the use of a bioprosthetic.
C. Neal Ellis et al. Meeting of The American Society of Colon and Rectal Surgeons 2012

15. BioLIFT Procedure Potential drawbacks of the BioLIFT technique
Requires extensive dissection in the intersphincteric space
High cost of the bioprosthetic materials

16. Unsuitable Cases for LIFT Procedure
External opening at intersphincteric groove
Abscess cavity in intersphincteric space (friable tract)
Large internal opening
Specific causes: TB, Crohn’s

17. VAAFT (Video-Assisted Anal Fistula Treatment)
Karl Storz endoscope
A small-calibered rigidscope equipped with an optical channel, a working channel and an irrigation channel

18. VAAFT

19. VAAFT: Meinero technique
Ablation of the fistula tract with unipolar electrode
Closure of the internal opening with stapler
Injection of cyanoacrylate into the fistula tract
Meniero P. Tech Coloproctol 2011

20. VAAFT: Meinero technique
98 patients with complex fistula
Performed under spinal anesthesia
Operation time: 30 to 120 minutes
Primary healing: 72 patients (73.5%)
Healing time: 2-3 months
No major complication or fecal incontinence
Meniero P. Tech Coloproctol 2011

21. Conclusion Management principles of complex anal fistula
Detailed assessment to exclude underlying disease
Anatomical +/- functional assessment
Tailored treatment
To control and eradicate sepsis (stages)
To remove tract and close internal opening
To preserve continence

22. Thank you

23. Assessment Clinical Radiological Endoanal ultrasound
Digital examination
Examination under anesthesia (EUA)
Anal manometry
Radiological
Endoanal ultrasound
Magnetic resonance imaging
Is it a simple or complex fistula

24. LIFT Procedure Prospective observational study
All cryptoglandular infections
May 2007 to September 2008
45 patients
33 transsphincteric
12 complex
Median follow-up: 9 (range, 2-16) months
Primary healing: 37/45(82.2%)
Median healing time : 7 (range, 4-10) weeks
Total bilirubin reached peak level earlier in groups with higher remnant liver volume. It reaches peak on day 1 to 2 post-operation in groups with remnant liver volume >=35%. While in groups with remnant liver volume <35%, total serum bilirubin peaked on post-operative day 3.
Shanwani et al DCR 2010

25. QMH Experience Since January 2009
25 patients
24 transphincteric fistula
1 suprasphincteric fistula
15 recurrenct
Median operating time: 39 minutes (range 15-73)
Median hospital stay: 1 day
Perianal incision healing time: 14 days
Closure of external opening: 31 days
Median follow-up 9.8 months (range )
2/25 (11%) recurrent rate
Since Janurary 2009, twenty-five patients were included (19 male and 6 female) with
median age of 48 years (range 22 – 64). There were 24 patients with transsphincteric
fistulas and one with suprasphincteric fistula. The median distance between the
external opening and the anal verge was 3 cm (range 1-15). Ten patients had first
presentation of anal fistulas while the others had recurrent fistulas with previous
interventions, including 11 with fistulotomy, 13 with seton insertion and 2 with anal
fistula plug. Four patients had more than one procedure before the LIFT procedure.
The median operating time and median hospital stay were 39 minutes (range 15-73)
only one day (range 0.5-4) respectively. Perianal incision wound healed completely in
22% of our patients in the first and then up to 89% in the second follow-up, at the
median time of 14 days (range 7-63). Closure of external opening of anal fistulas was
noted in 72% of our patients in the first and 89% in the second follow-up, at the
median time of 31 days (range 7-63). There were no complications such as
incontinence or bleeding.
During the median follow-up of 9.8 months (range ), two patients (11%) had
persistent fistula after the LIFT procedure. One patient had suprasphincteric fistula

26. VAAFT
To identify the internal opening under direct endoscopic view and then close it with suturing or stapler
To ablate or remove the granulation tissue along the fistula tract
To fill the fistula tract with bio-prosthetic material

27. There is
great variation in both technical difficulty and efficacy
among other sphincter-preserving options for complex
cryptoglandular fistulas. Mucosal advancement flaps are
technically challenging and are associated with recurrence
rates that vary from 2 to 54% [10–14]. These failure rates
may result from some mobilization of structures or a
tendency for the flap to retract or dehisce. Moreover,
advancement flaps are often associated with postoperative
incontinence, and the incidence of this complication has
been reported to approach 35% in some series [14]. Fibrin
glue injection is a technically easy, low-risk technique but
results have been disappointing, showing success rates as
low as 16% long term [15–20]. Similarly, the use of the
anal fistula plug is a simple, sphincter-sparing technique,
but very expensive [21] and with reported success rates
ranging between 29% and 87% [22–26].
The latest conservative technique reported in literature
is the ligation of intersphincteric fistula tract (LIFT) pro-
cedure. This approach consists of ligation of the tractfistula tract. In a group of 17 patients with a median follow-
up of 9 months, they report an 82.3% healing rate. This
approach, like VAAFT, is aimed at destroying the tract and
preserving the sphincters, but it is a procedure performed
blindly, without advantages in identifying the internal
opening, secondary tracts and abscess cavities. The ratio-
nale of the VAAFT technique is based on the same prin-
ciples as other procedures for closing the internal opening
and obliterating the track, where the real innovation is the
precise identification of the fistula anatomy and of the
internal opening by fistuloscopy and fulguration of the tract
walls under direct vision. This approach allows the iden-
tification and treatment of all the secondary tracts, and the
abscess cavities connected to the main pathway. We
believe that the adoption of fistuloscopy together with a
good technique for closing the internal opening (with a
stapler or manually) and reinforcing the closure of the
opening from the inner side of the staple/suture line is the
most effective way of achieving a high healing rate for